Download WC May/June 2012 - Wound Care Advisor

Caring for chronic
wounds: A knowledge
update
Wound care is a lot more sophisticated than it
used to be. Here’s what you should know about
assessing and managing chronic wounds.
By Patricia A. Slachta, PhD, RN, ACNS-BC, CWOCN
W
ound care has come a long
way in just a few decades.
With our expanded knowledge of wound healing
and recent advances in treatment, we’re
now able to assess wounds more accurately, recognize wound-related problems
sooner, provide better interventions, and
reduce morbidity.
To bring you up to date on current
evidence-based wound management, this
article focuses on assessing patients with
chronic wounds, optimizing wound healing with effective wound-bed preparation,
and selecting an appropriate dressing.
causing minimal functional loss in the
part of the body with the wound.
Identifying the cause of the wound also
is essential. If the wound etiology is unknown, explore the patient’s medical history (including medication history) for
clues to possible causes. Also review the
patient’s history for conditions that could
impede wound healing. (See What factors
hamper healing?)
Other important aspects of assessment
include evaluating the patient’s nutritional
status, quantifying the level of pain (if
present), and gauging the patient’s selfcare abilities.
Wound chronicity and cause
General physical appearance
Developing an appropriate plan of care
hinges on conducting a thorough, accurate
evaluation of both the patient and the
wound. The first step is to determine
whether the wound is acute or chronic.
• A chronic wound is one that fails to
heal within a reasonable time—usually
3 months.
• An acute wound heals more quickly,
Conduct a general head-to-toe physical examination, focusing on the patient’s height,
weight, and skin characteristics.
Identifying the
cause of the
wound is essential.
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Height, weight, and weight trend
On admission, the patient’s height and
weight should be measured to ensure appropriate nutritional and pharmacologic
management. After a weight gain or loss,
various factors may complicate wound
healing. For instance, involuntary weight
loss and protein-energy malnutrition may
occur in both acute-care and long-termcare patients.
Especially note trends in your patient’s
weight. For a long-term-care patient, a 5%
weight loss over 30 days or a 10% loss
May/June 2012 • Issue 1, Number 1 • Wound Care Advisor
over 180 days is considered involuntary.
Arrange for a nutritional consult for any
patient with an involuntary weight loss, as
adequate nutrition is essential for general
well-being and wound healing. (See A
wound on the mend.)
A wound on the mend
In this healing wound, note the epithelialization around
the wound edges. If drainage is present in a wound
such as this, suspect bioburden and consider using an
antimicrobial dressing, such as silver.
Skin color
Skin texture and turgor
Generally, healthy skin feels smooth and
firm and has an even surface and good
turgor (elasticity). To test turgor, gently
grasp and pull up a fold of skin on a site
such as the anterior chest below the clavicle. Does the skin return to place almost
immediately after you release it, or does it
stand up (“tent”)? Tenting indicates dehydration. But keep in mind that skin loses
elasticity with age, so elderly patients normally have decreased turgor.
Skin temperature
With normal circulatory status, the skin is
warm and its temperature is similar bilaterally. Areas of increased warmth or coolness suggest infection or compromised circulation. Be sure to check the temperature
of skin surrounding the wound.
Wound assessment
Proper wound assessment can significantly
influence patient outcome. Measure the
wound carefully and document the condition of the wound bed. Remember that accurate descriptions are essential for guid-
© Nursing Educational Programs and Services
Evaluate the patient’s skin color in light of
ethnic background. If you note erythema—
especially on a pressure point over a bony
prominence—examine this area carefully
for nonblanching erythema. Keep in mind
that darkly pigmented skin doesn’t show
such erythema and subsequent blanching,
yet the patient may still be in jeopardy. So
in dark-skinned patients, check for differences in skin color, temperature, or firmness compared to adjacent tissue; these differences may signify skin compromise.
ing ongoing wound care. Repeat wound
measurement and wound-bed assessment
at least weekly, after the wound bed has
been cleaned and debrided.
Keep in mind that assessing a chronic
wound can be challenging. Wounds commonly have irregular shapes that can
change quickly. Also, the multiple clinicians caring for the same patient may each
describe the wound a bit differently.
Wound location
Note the precise anatomic location of the
wound, as this can influence the wound
care plan. A venous ulcer on the lower
leg, for instance, requires different care
than an arterial ulcer in the same site or
a pressure ulcer on the ischium.
Circumference and depth
Use a paper or plastic measuring device to
measure wound circumference and depth
in centimeters (cm) or millimeters (mm).
To promote accurate assessment of healing, be sure to use the same reference
points each time you measure the wound.
You can use several methods to meas-
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What factors hamper healing?
A wound is a dynamic entity.
The wound bed’s microenvironment changes constantly, and
various local and systemic factors may impair wound healing.
To ensure an appropriate plan of
care, check your patient’s history
and physical findings for factors
that can impede healing, such
as those described below.
Infection
Wound infection prolongs the
inflammatory phase of healing
and delays collagen synthesis,
which in turn delays wound
granulation and epithelialization.
Previously, clinicians classified
wounds simply as infected or
not infected. Now we know
there’s a continuum ranging
from wound contamination, colonization, and critical colonization (bacteria present on the
wound surface but not penetrating viable tissue) to wound infection. Also, if the wound contains biofilms (polysaccharide
matrices that envelop and protect the bacteria), antibiotic efficacy may decrease.
Poor tissue perfusion and
oxygenation
Wound repair relies on cells receiving enough oxygen to fuel
their repair functions (specifically, collagen synthesis and epithelial proliferation and migration). Although phagocytic
activity occurs in both hypoxic
and oxygenated tissue, bactericidal ability depends mainly on
oxygen. Necrotic tissue in the
wound increases the need for
phagocytosis and consequently
oxygen. Tissue edema also limits oxygen flow to the wound.
Excessive wound drainage
Too much wound drainage may
impair healing by placing pressure on granulating tissue; also,
the drainage may harbor bacteria.
Poor nutrition
Poor nutrition has many effects
on the skin, tissues, and healing.
An anabolic process, healing requires adequate amounts of
proteins, calories, vitamins, minerals, and water. Thus, the patient needs to be in an anabolic
state. Protein-energy malnutrition may occur if the patient is
in a catabolic state (in which the
body breaks down protein and
energy stores).
Adequate nutrition also is important for collagen synthesis
(which requires proteins, vitamin C, zinc, and iron), collagen
ure circumference. The most commonly
used method of measurement is done in
the head to toe direction. Measure the
wound at its greatest length in that direction & measure the width at a 90 degree
angle, at the widest point of the wound.
Then multiply these two measurements
(greatest length x greatest width) to obtain
the total wound area. Although such linear
measurements are imprecise, they yield
gross information relative to wound healing when repeated over time.
Classify wound depth as partial thick-
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fiber cross-linking (which requires copper and B-complex vitamins), and production of energy for wound healing (which
requires calories).
Diseases
Diabetes mellitus impedes
wound-bed oxygenation and
wound healing by causing angiopathic changes in vessels.
Cancer, renal disease, and hepatic disease also may slow
wound healing.
Medications
Corticosteroids’ anti-inflammatory actions impede movement
of neutrophils and macrophages
into the wound. This makes the
wound more susceptible to infection and slows healing, as
macrophages attract the growth
factors that stimulate collagen
synthesis. Immunosuppressive
drugs also affect the inflammatory response and can hamper
healing.
Aging
With increased age, cell regeneration slows, which in turn
leads to a decreased rate of
wound contraction, impaired
wound remodeling, and reduced
reepithelialization.
ness or full thickness.
• Partial-thickness wounds are limited to
the skin layers and don’t penetrate the
dermis. They usually heal by reepithelialization, in which epidermal cells regenerate and cover the wound. Abrasions, lacerations, and blisters are
examples of partial-thickness wounds.
• Full-thickness wounds involve tissue
loss below the dermis.
(Note: Pressure ulcers usually are classified by a four-stage system and diabetic
foot ulcers by a grading system. Both sys-
May/June 2012 • Issue 1, Number 1 • Wound Care Advisor
tems are beyond this article’s scope.)
Measure and record wound depth
based on the deepest area of tissue loss.
To measure depth, gently place an appropriate device (such as a foam-tipped applicator) vertically in the deepest part of
the wound, and mark the applicator at the
patient’s skin level. Then measure from
the end of the applicator to the mark to
obtain depth.
Picturing a necrotic wound
In this wound, approximately half the tissue is nonviable. Note the undermining at the 12 o’clock position.
For such a wound, patient assessment must include
nutritional status and wound bioburden. If exudate is
present, absorbent silver is a good dressing option. For
minimal exudate, an enzyme or impregnated gel gauze
may be adequate.
Surrounding skin and tissue
© Nursing Educational Programs and Services
Inspect for and document any erythema,
edema, or ecchymosis within 4 cm of the
wound edges, and reevaluate for these
signs frequently. Because compromised skin
near the wound is at risk for breakdown,
preventive measures may be necessary.
Appearance of wound-bed tissue
Document viable tissue in the wound bed
as granulation, epithelial, muscle, or subcutaneous tissue. Granulation tissue is
connective tissue containing multiple small
blood vessels, which aid rapid healing of
the wound bed; appearing red or pink, it
commonly looks shiny and granular. Epithelial tissue consists of regenerated epidermal cells across the wound bed; it may
be shiny and silvery.
Check for nonviable tissue (also called
necrotic, slough, or fibrin slough tissue),
which may impede wound healing. It may
vary in color from black or tan to yellow,
and may adhere firmly or loosely to the
wound bed. (See Picturing a necrotic
wound.)
Be sure to document the range of colors
visible throughout the wound. Identify the
color that covers the largest percentage of
the wound bed. This color—and its significance—guide dressing selection.
Wound exudate
Document the amount, color, and odor of
exudate (drainage) in the wound. Exudate
with high protease levels and low growth
factor levels may impede healing.
If the wound is covered by an occlusive
dressing, assess exudate after the wound has
been cleaned. Describe the amount of exudate as none, minimal, moderate, or heavy.
Describe exudate color as serous,
serosanguineous, sanguineous, or purulent.
Serous exudate is clear and watery, with
no debris or blood present. Serosanguineous exudate is clear, watery, and
tinged pink or pale red, denoting presence
of blood. Sanguineous exudate is bloody,
indicating active bleeding. Purulent exudate may range from yellow to green to
brown or tan.
Describe wound odor as absent, faint,
moderate, or strong. Note whether the
odor is present only during dressing re-
Check for nonviable
tissue, which may
impede wound healing.
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Where to get more information
The following websites offer additional information
on wound care topics.
Clinical guidelines for diabetic neuropathic ulcer
care:
http://care.diabetesjournals.org/content/22/8/1354.full.pdf
Clinical guidelines for venous ulcer care:
http://www.guideline.gov/search/search.aspx?
term=venous+ulcers
Pressure ulcer staging:
www.npuap.org/pr2.htm
Pressure ulcer treatment guidelines:
http://www.epuap.org/guidelines/Final_Quick_
Treatment.pdf
Wound-bed preparation:
http://www.woundbedprep.com/pdfs/english.pdf
moval, if it disappears after the dressing is
discarded, or if it permeates the room.
and in the wound bed to check for undermining and tracts. Undermining, which
may occur around the edges, presents as a
space between the intact skin and wound
bed (resembling a roof over part of the
wound). It commonly results from shear
forces in conjunction with sustained pressure. A tract, or tunnel, is a channel extending from one part of the wound
through subcutaneous tissue or muscle to
another part.
Measure the depth of a tract or undermining by inserting an appropriate device
into the wound as far as it will go without
forcing it. Then mark the skin on the outside where you can see or feel the applicator tip. Document your findings based on a
clock face, with 12 o’clock representing the
patient’s head and 6 o’clock denoting the
feet. For instance, you might note “2.0-cm
undermining from 7:00 to 9:00 position.”
Pain level
Wound edges
Wound edges indicate the epithelialization
trend and suggest the possible cause and
chronicity of the wound. The edges should
attach to the wound bed. Edges that are
rolled (a condition called epibole) indicate
a chronic wound, in which epithelial cells
are unable to adhere to a moist, healthy
wound bed and can’t migrate across and
resurface the wound.
Undermining and tracts
Gently probe around the wound edges
Find out which
pain-management
techniques have relieved
your patient’s pain in
the past.
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Ask the patient to quantify the level of
pain caused by the wound, using the pain
scale designated by your facility. Find out
which pain-management techniques have
relieved your patient’s pain in the past; as
appropriate, incorporate these into a painmanagement plan. Reevaluate the patient’s
pain level regularly.
Wound-bed preparation
An evolving science, wound-bed preparation is crucial for minimizing or removing
barriers to healing. The goal is to minimize
factors that impair healing and maximize
the effects of wound care. The key elements of wound-bed preparation are controlling bioburden and maintaining moisture
balance. (For online resources on woundbed preparation and other wound-care topics, see Where to get more information.)
Controlling bioburden
Necrotic tissue and exudate harbor bacteria. A wound’s bioburden—the number of
contaminating microbes—contributes to
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Wound debridement techniques
A wound may be debrided using
a mechanical, chemical, sharp,
or autolytic technique. Mechanical debridement is nonselective,
removing all types of tissue
from the wound. Chemical,
sharp, and autolytic debridement are selective methods that
remove only necrotic tissue.
• Mechanical debridement
may be achieved with
whirlpool therapy, pulsatile
lavage, wet-to-dry gauze
dressings, and irrigation using a 35-mL syringe and a
19G angiocatheter. Each of
these methods has specific
precautions. Important: Don’t
•
•
moisten a wet-to-dry dressing before removing it, as
this defeats its purpose.
In chemical debridement, an
enzymatic ointment is applied topically to the necrotic
tissue. Researchers suggest
using maggot therapy for
chemical debridement as the
maggots secrete a proteolytic enzyme with effects
similar to those of enzyme
ointments.
Sharp debridement involves
use of a sharp instrument,
such as a scalpel, currette, or
scissors, on nonviable tissue.
Although usually done at the
poor healing. All chronic wounds are considered contaminated or colonized, but not
necessarily infected. In a colonized
wound, healing is impeded as bacteria
compete for nutrients; also, bacteria have
harmful byproducts. To control bioburden,
the wound must be cleaned and necrotic
tissue must be debrided.
Cleaning the wound. Clean the wound
before assessing it and applying a dressing.
Use a noncytotoxic agent (typically, potable
water, normal saline irrigating solution, or
an appropriate wound-cleaning agent).
Antiseptic solutions generally aren’t recommended for wound irrigation or dressings
because they’re toxic to fibroblasts and other wound-repairing cells. If you must use
such a solution, make sure it’s well diluted.
To ensure gentle cleaning or irrigation,
pour solution over the wound bed or gently flush the wound with solution (using a
60-mL catheter-tip syringe) until the
drainage clears. Know that pressurized irrigation techniques and whirlpool therapy
aren’t recommended for wound cleaning
because they disturb cell proliferation in
the wound bed.
Debriding the wound. Debridement re-
•
bedside, it may be performed in the operating
room (called surgical sharp
debridement) if a large
amount of tissue needs to be
removed or the procedure
might cause excessive discomfort, bleeding, or fluid
loss. Lasers also can be
used.
Autolytic debridement has
become more popular since
the late 1970s, when transparent film dressings were
introduced. The many additional dressings now available provide an environment
moves slough and necrotic tissue. Nonselective debridement techniques remove
any type of tissue within the wound bed,
whereas selective methods remove only
necrotic tissue. (See Wound debridement
techniques.)
Maintaining moisture balance
To maintain moisture balance in the
wound bed, you must manage exudate
and keep the wound bed moist. The proper dressing (which may stay in place for
days or longer) supports moist wound
healing and exudate management. To minimize fluid pooling, a drain may be inserted into the wound. Negative-pressure
wound therapy also may aid removal of
excess exudate.
Wound Care Advisor • May/June 2012 • Issue 1, Number 1
Clean the wound
before assessing
it and applying
a dressing.
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Dressing options for necrotic wounds
Use this chart to guide selection of an appropriate dressing for a necrotic wound. As with clean
wounds, dressings for necrotic wounds depend on such factors as wound stage, exudate status,
wound bed appearance, and amount of drainage. This chart provides separate dressing choices for
minimally, moderately, and heavily draining wounds. (Note: To reduce bioburden in a wound that
doesn’t contain dried eschar, use a cadexomer iodine pad or gel, a silver dressing, or honey [a
bacteriostatic product].)
Minimally draining wound
Moderately draining wound
Heavily draining wound
Transparent film
Promotes autolytic debridement
• Apply skin protector to
periwound area.
• Make sure dressing extends at
least 1" beyond wound edge.
• Change dressing q 3 days, or
p.r.n. if leakage occurs.
Hydrocolloid (thin)
Promotes autolytic debridement
• Apply skin protector to periwound
area per product directions.
• Make sure dressing extends at
least 1" beyond wound edge.
• As needed, tape edges to prevent
rolling.
• Change q 3 days, or p.r.n. if
leakage occurs.
Hydrocolloid (thick)
Promotes autolytic debridement
• Apply skin protector to periwound
area per product directions.
• Make sure dressing extends at
least 1" beyond wound edge.
• As needed, tape edges to prevent
rolling.
• Change q 3 days or p.r.n. if
leakage occurs.
Hydrogel (amorphous)
Provides moisture to wound, which softens eschar
• Apply skin protector to periwound area.
• Apply thin layer of gel over entire wound bed.
• Cover with a low adherent dressing.
• Change q 24 hours or per product directions.
Alginate or hydrofiber (if wound doesn’t contain dried eschar)
Absorbs drainage and promotes autolytic debridement
• Apply skin protector to periwound area.
• Cut dressing to fit wound if needed, and cover with secondary
absorbent dressing.
• Change q 24 hours or p.r.n. if strikethrough leakage occurs.
If dressing isn’t saturated, may change q 48 hours.
Enzymatic ointments
Used for wounds with eschar, slough, or both
• Apply skin protector to periwound area.
• Apply layer of ointment over wound bed; cover with gauze dampened
with normal saline solution and with secondary absorbent dressing;
and secure with tape per product directions.
• Change q 24 hours or per product directions.
• If needed, score hardened eschar with scalpel or scissors to aid
ointment penetration.
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May/June 2012 • Issue 1, Number 1 • Wound Care Advisor
Choosing an appropriate dressing
The wound dressing plays a major role in
maintaining moisture balance. Dressing selection is challenging because of the large
number and variety of dressings available.
Each product has specific actions, benefits,
and drawbacks, so determining which
dressing best suits the patient’s needs is a
multifaceted process.
Dressing choice depends on such factors as wound type and appearance, exudate, presence or absence of pain, and required dressing change frequency. (See
Dressings Options.)
In a traditional dressing, gauze is applied in layers. The initial (contact) layer in
the wound bed absorbs drainage and
wicks it to the next layer; most often, this
layer consists of woven cotton gauze or
synthetic gauze. Remove the gauze gently,
because it may be stuck to the wound or
incision (especially if the gauze is cotton).
For easier removal, moisten the dressing
with normal saline solution to loosen it.
With a traditional dressing, the cover
layer or secondary dressing is an abdominal pad with a “no-strike-through” layer
next to the outside of the dressing. Be
aware that wet-to-dry dressings are highly
discouraged for their nonselective debriding effect and inability to provide a moist
wound bed.
Reassess the patient’s wound at least
weekly (after preparing the wound bed
and dressing the wound) to determine
healing progress. Keep in mind that
wound-care management is a collaborative
effort. Once you’ve assessed the patient,
discuss your findings and subsequent
wound management with other members
of the team.
cessitate lifestyle changes and lead to severe physical consequences ranging from
infection to loss of function and even
death. By performing careful assessment,
tailoring patients’ wound care to wound
etiology, and using evidence-based protocols to manage wounds, you can promote
speedier wound healing, help lower mor■
bidity, and improve quality of life.
Selected references
Bryant RA, Nix DP. Acute and Chronic Wounds:
Current Management Concepts. 4th ed. St. Louis,
MO: Mosby; 2011.
Gardener SE, Frantz R, Hillis SL, Park H, Scherubel
M. Diagnostic validity of semiquantitative swab cultures. Wounds. 2007;(19)2:31-38.
Krasner DL, Rodeheaver GT, Sibbald RG. Chronic
Wound Care: A Clinical Source Book for Healthcare
Professionals. 4th ed. Wayne, PA: HMP Communications; 2007.
Langemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care.
2006;19(4):206-211.
Langemo DK, Anderson J, Hanson D, Hunter S,
Thompson P. Measuring wound length, width, and
area: which technique? Adv Skin Wound Care.
2008;21:42-45.
Milne C, Armand OC, Lassie M. A comparison of
collagenase to hydrogel dressings in wound debridement. Wounds. 2010:22(11):270-274.
National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and
Treatment of Pressure Ulcers: Clinical Practice
Guideline. Washington, DC: National Pressure Ulcer
Advisory Panel; 2009.
Ovington LG. Hanging wet-to-dry dressings out to
dry. Adv Skin Wound Care. 2002;15(2):79-86.
Sibbald RG, Coutts P, Woo KY. Reduction of bacterial burden and pain in chronic wounds using a new
polyhexamethylene biguanide antimicrobial foam
dressing—clinical trial results. Adv Skin Wound
Care. 2011;24(2):78-84.
Solway DR, Consalter M, Levinson DJ. Microbial cellulose wound dressing in the treatment of skin tears
in the frail elderly. Wounds. 2010:22(1):17-19.
Wound care wisdom
Wound Ostomy and Continence Nurses Society.
Guideline for Prevention and Management of Pressure Ulcers. Mt. Laurel, NJ: Author; 2010
Getting wiser about wound care will help
your patients achieve good outcomes.
Poor wound healing can be frustrating to
patients, family members, and healthcare
providers alike. Chronic wounds may ne-
Patricia A. Slachta is a Clinical Nurse Specialist
at The Queens Medical Center in Honolulu,
Hawaii and an adjunct nursing instructor at the
Technical College of the Lowcountry in Beaufort,
South Carolina.
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